Transcript of "Employment Network RFP"

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SOCIAL SECURITY
February 28, 2007
Ladies and Gentlemen:
You are invited to submit a proposal in accordance with the requirements of the enclosed
solicitation number SSA-RFP-07-0010F, "Employment Networks (EN) for the Ticket to Work
and Self-Sufficiency Program."
The Ticket to Work and Self-Sufficiency Program is the centerpiece of the Ticket to Work and
Work Incentives Improvement Act of 1999. This program provides Social Security beneficiaries
with disabilities more choices for receiving employment services. Under this program the Social
Security Administration (SSA) is issuing Tickets to eligible beneficiaries who, in turn, may
assign those Tickets to an Employment Network (EN) of their choice to obtain employment
services, vocational rehabilitation services or other support services necessary to achieve a
vocational goal. The EN will assume responsibility for the coordination and delivery of
appropriate employment, vocational rehabilitation or other support services to those beneficiaries
who have assigned tickets to the EN.
We have simplified the process for completing and submitting an EN contract proposal.
Attached is a Request for Proposal (RFP) package that explains the duties of an EN contractor,
requirements that must be met in order to be awarded an EN contract, and directions for
submitting an EN contract proposal. To submit a proposal, please follow the steps listed below:
• Read carefully the information and instructions found in Parts II, III, IV, and V of the
RFP package.
• Complete all of the sections found in Part III, EN Proposal Documentation Requirements.
• Submit the original Part III in its entirety, complete with all required forms (signed and
dated) and proofs of qualifications and liability insurance coverage to:
Social Security Administration
Employment Network Proposals
Attn: Employment Network Contracts Team
P.O. Box 17778
Baltimore, MD 21235-17778
In lieu of submitting a hardcopy proposal, offerors may submit their proposals electronically to
ENcontracts@ssa.gov. DO NOT submit the entire RFP package.
This RFP package is available for downloading at www.ssa.gov/work. Any amendments to
the RFP will be issued electronically via this website. It is the offeror’s responsibility to

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check this website periodically for any such amendments. This RFP replaces all previous
RFPs and amendments.
As SSA continues to release Tickets based on new accretions to the disability roles and/or Ticket
eligibility, this solicitation will remain open continuously until further notice. However, we
strongly encourage offerors to submit their proposals as soon as possible.
For more information about the Ticket-to-Work Program, please visit the following websites:
Social Security Administration's website: www.ssa.gov/work Operations Support Manager
(MAXIMUS) website: http://www.yourtickettowork.com
SSA staff is available to answer any questions you may have about becoming an EN contractor
and submitting a contract proposal. Please direct your questions to the Employment
Networks Contract Team as follows:
Email ENcontracts@ssa.gov
Toll Free # 866-584-5180
Toll Free TDD 866-584-5181
Fax 410-597-0429
In accordance with Section 1148(f) of the Social Security Act, this solicitation is not open to
Federal agencies.
Sincerely,
/s/
Erica Day
Contracting Officer
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SSA-RFP-07-0010F
PART I - PRICE
Table of Contents
Social Security Administration ...................................................................................................1
PART I – PRICE.............................................................................................................................3
SECTION 1: SUPPLIES/SERVICES AND PRICE...................................................................................3
SECTION 2: TRAVEL EXPENSES .........................................................................................................4
PART II – STATEMENT OF WORK............................................................................................5
SECTION 1: QUALIFICATION REQUIREMENTS FOR EMPLOYMENT NETWORKS........5
B. Timeframe for Submitting an Individual Work Plan.................................................................9
A. Employment Network Referrals to State VR Agencies....................................................................................9
If a dispute arises under the agreement between the EN and State VR agency, the following steps
would be used to resolve the dispute:............................................................................................10
SECTION 7: EMPLOYMENT NETWORK TRAINING .................................................................................12
SECTION 10: EMPLOYMENT NETWORK REPORTING REQUIREMENTS......................15
SECTION 11: PAYMENTS TO EMPLOYMENT NETWORKS..................................................................16
PART III – EN PROPOSAL DOCUMENTATION REQUIREMENTS.....................................21
SECTION 1: Instructions for Completing Standard Form SF-1449.............................................21
Block 17a..............................................................................................................................................................21
Block 17b..............................................................................................................................................................21
Block 30a..............................................................................................................................................................21
Block 30b..............................................................................................................................................................21
Block 30c..............................................................................................................................................................21
PART IV – CONTRACT CLAUSES............................................................................................43
52.224-1 -- Privacy Act Notification (APR 1984)............................................................................................43
SECTION 4: ADDITIONAL CLAUSES INCORPORATED BY FULL TEXT............................................48
Legislation ............................................................................................................................................................52
SSA’s Approach to Systems Security...................................................................................................................52
Role of the SSA Systems Security Officer...........................................................................................................52
General Systems Security Standards.....................................................................................................................53
Baltimore, MD 21235-6401......................................................................................................54
PART V – SOLICITATION PROVISIONS.................................................................................62
PART I – PRICE
SECTION 1: SUPPLIES/SERVICES AND PRICE
a) The total Firm–Fixed-Price of this contract is $0 where in consideration for satisfactory
performance of work as specified by the statement of work, the Contactor shall be paid in
accordance with the Payment to ENs (PART II, SECTION 11). The government does not
guarantee any minimum or maximum amount of work and/or dollar value associated with
this contract.
b) The contractor shall furnish all necessary personnel, materials, services, facilities and
equipment, except as may be otherwise specified herein, and perform all tasks necessary for ,
or incidental to, the performance of EN services.
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SSA-RFP-07-0010F
PART I - PRICE
SECTION 2: TRAVEL EXPENSES
The Contractor is responsible for all travel costs necessary to accomplish the objectives of this
contract and will not be reimbursed for such costs by the government.
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SSA-RFP-07-0010F
PART II – STATEMENT OF WORK
PART II – STATEMENT OF WORK
SECTION 1: QUALIFICATION REQUIREMENTS FOR EMPLOYMENT NETWORKS
An Employment Network (EN) must meet and maintain compliance with both general selection
criteria and specific selection criteria as follows:
A. General Qualification Requirements
1. Have systems in place to protect the confidentiality of personal information about
beneficiaries seeking or receiving services;
2. Have the capability to provide or arrange for the delivery of services to beneficiaries
throughout the EN's selected service area;
3. Not discriminate on the basis of a beneficiary’s age, gender, race, color, creed or national
origin in providing services;
4. Have sufficient staff and facilities available in the EN's selected service area to provide or
arrange for the delivery of services to beneficiaries;
5. Comply with the terms and conditions of the contract with SSA, including delivering or
coordinating the delivery of employment services, vocational rehabilitation (VR) services
or other support services and complying with information reporting requirements;
6. Maintain accounting procedures and control operations necessary to document contractor
costs and efforts and
7. Carry general and/or professional liability insurance and, as appropriate, medical liability
insurance.
B. An entity may be precluded from becoming an EN or may have its EN contract
terminated if it:
1. Has had its license, accreditation, certification or registration suspended or revoked for
reasons concerning professional competence or conduct or financial integrity or
2. Has surrendered a license, accreditation, certification or registration with a disciplinary
proceeding pending or
3. Is precluded from Federal procurement or non-procurement programs or
4. Does not carry current general and/or professional liability insurance and, as appropriate,
medical liability insurance.
C. Specific Qualification Requirements
In addition to the above general criteria, an EN must also meet all of the following specific
criteria:
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SSA-RFP-07-0010F
PART II – STATEMENT OF WORK
1. Have applicable certificates, licenses or other credentials to provide employment
services, VR services or other support services in the State as required by State law; or in
the absence of such State requirements, have credentials that demonstrate qualifications
to provide such services.
• An EN shall inform SSA through the Operations Support Manager (OSM)
contractor if its license, accreditation or certification is revoked or suspended
or otherwise changed during performance of the contract within 5 calendar
days of receiving notice of the revocation, suspension or change.
• Failure to notify the OSM of a change in the status of the EN contractor's
license, accreditation or certification may be grounds for termination of the
contract for cause.
2. Ensure that medical and related health services, if any, to which the EN and beneficiary
agree are necessary to support attainment of the beneficiary's employment goal, are
provided under the formal supervision of persons licensed to prescribe or supervise the
provision of these services in the State in which the services are performed.
3. Employ staff and/or utilize providers who are:
• qualified under applicable certification, licensing or registration standards that apply
to their profession as required by State law; or in the absence of such requirements,
• otherwise qualified based on education or experience.
D. Submitting Proof of Qualifications
To meet the required specific criteria, an offeror must submit with their proposal one (1) of
the following:
1. A copy of the license or certification, where State law requires licensing or certification
to provide employment services, VR services or other support services.
2. Evidence of certification or accreditation that establishes an offeror's qualifications to
provide or arrange for the provision of employment services, VR services or other
support services, where there is no State law requirement.
NOTE: All licenses, certifications, and accreditations as required under 1 or 2 above
must be current at the time of contract award.
3. In the absence of 1 or 2 above, other documentation that demonstrates an offeror's
qualifications to provide or arrange for the provision of employment services, VR
services or other support services. This documentation must clearly demonstrate how the
offeror’s qualifications are applicable to the requirements of this solicitation. Such
qualifications may be based on education and/or experience. Some examples of
documentation showing qualifications based on education and/or experience include, but
are not limited to, the following:
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PART II – STATEMENT OF WORK
• An employer's statement that its human resources department includes staff with
degrees in vocational counseling, human relations, teaching or psychology; or
• A public or private school's statement that its guidance counselors have experience in
assisting students with disabilities to achieve specific job skills that lead to
employment through job training programs or other services or programs; or
• Contracts with State VR agencies to provide employment, VR or other support
services.
Documentation of your qualifications shall be made under letter P of the EN
Information Sheet found in Part III, Section 2, of this solicitation.
SECTION 2: DISTRIBUTION AND ASSIGNMENT OF TICKETS
Participation in the Ticket Program is voluntary. A beneficiary with a Ticket who decides to
participate in the program may take the Ticket to any EN of his or her choice (or to a State VR
agency).
A. In the event a beneficiary wishes to assign his or her Ticket, the EN shall take the following
steps:
1. Verify through the OSM that the beneficiary has a Ticket, has not assigned the Ticket to
another EN, and is eligible to assign the Ticket.
2. Provide the beneficiary with a comprehensive explanation of the services it offers.
3. Mutually develop an individual work plan (IWP) with the beneficiary.
4. Initiate Ticket assignment by submitting a copy of the signed document to the OSM as
described in Part I, Section 3 (Individual Work Plan Requirements for Employment
Networks), of this solicitation.
B. An EN is not obligated to accept a Ticket from a beneficiary but shall not discriminate in the
provision of services based on a beneficiary's age, gender, race, color, creed or national
origin.
C. Once the Ticket is assigned to an EN and that assignment is confirmed by the OSM, the EN
may begin working with the beneficiary to achieve a successful employment outcome.
D. An EN may end its relationship with a beneficiary at any time it is no longer willing or able
to provide services to that beneficiary. In such cases the EN shall inform both the
beneficiary and the OSM in writing.
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PART II – STATEMENT OF WORK
SECTION 3: INDIVIDUAL WORK PLAN REQUIREMENTS FOR EMPLOYMENT
NETWORKS
The IWP is a written agreement signed by both the beneficiary (or a representative of the
beneficiary) and the EN that describes the specific employment services, VR services or other
support services that will be provided to assist the beneficiary to obtain an employment goal.
ENs must provide employment services, VR services or other support services under an IWP for
each beneficiary served.
A. Individual Work Plan Requirements
At a minimum, the IWP must include the following five (5) components:
1. A statement describing the vocational goal developed with the beneficiary;
2. A statement describing the services and supports to be provided by or through the EN to
the beneficiary to accomplish the vocational goal in (1) above;
3. A statement of any terms and conditions related to the provision of the services and
supports in (2) above;
4. A statement whereby the beneficiary shall give permission to the EN to contact
employers on the beneficiaries behalf to verify or obtain evidence of work and
earnings.
5. The following nine (9) statements relating to an EN's responsibilities to the beneficiaries
for whom it provides services:
a. A statement that the EN may not request or receive any compensation for the
costs of services and supports from the beneficiary;
b. A statement that the beneficiary, if dissatisfied with the services being provided by the
EN, may unassign the Ticket at any time by notifying both the EN and the OSM,
thereby terminating the relationship with the EN;
c. A statement regarding the dispute resolution process available to the beneficiary,
including information on the availability of advocacy services and assistance in
resolving disputes through the State Protection and Advocacy (P&A) System;
d. A statement that the beneficiary's personal information will be kept private and
confidential, including Social Security Number and information about the
beneficiary's disability;
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PART II – STATEMENT OF WORK
e. A statement explaining that the beneficiary can have a copy of the IWP in an
accessible format chosen by the beneficiary at any time;
f. A statement of the conditions under which an EN may amend the IWP or terminate the
relationship;
g. A statement explaining the process for amending the IWP (the IWP may be amended
if both the beneficiary and the EN agree to the change);
h. A statement that only qualified employees and/or providers, as described in Section 1,
Qualifications Requirements for Employment Networks, will be used to furnish
services; and
i. A statement that if any medical or related health services are provided, they will be
provided under the supervision of persons licensed to prescribe or supervise the
provision of these services in the State in which the services are performed.
6. A detailed listing of the specific employment goals and services with corresponding
timeframes to be provided to the beneficiary.
B. Timeframe for Submitting an Individual Work Plan
A copy of the IWP shall be submitted to the OSM. In order to expedite the Ticket
assignment ENs are encouraged to submit the IWP immediately, but in all cases no later than
2 weeks after it has been signed by both the beneficiary (or a representative of the
beneficiary) and the EN. The OSM shall review the IWP for completeness.
NOTE: Ticket assignment is contingent upon the OSM’s receipt and confirmation of all
the requisite information as described above. The effective date of the Ticket
assignment will be the first day on which the beneficiary is eligible to assign the Ticket
and both the beneficiary and a representative of the EN sign the IWP.
SECTION 4: REFERRAL AGREEMENTS BETWEEN EMPLOYMENT NETWORKS
AND STATE VR AGENCIES
A. Employment Network Referrals to State VR Agencies
1. An EN may refer a beneficiary it is serving under the Ticket Program to a State VR
Agency for services if the State VR agency and the EN have a signed agreement
describing the conditions under which the State VR agency will provide services under the
Ticket Program. The State VR agency and the EN shall sign this agreement before the EN
refers any beneficiary to the State VR agency for services.
2. Normally the agreement should be broadly worded so that it applies to all beneficiaries
that the EN may refer to the State VR agency. However, an EN and a State VR agency
may wish to enter into specific agreements to meet the needs of individual beneficiaries.
3. The EN shall submit, within two weeks of signing, a copy of this agreement to the OSM.
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B. Resolving Agreement Disputes Between the Employment Network and State VR
Agency
If a dispute arises under the agreement between the EN and State VR agency, the following
steps would be used to resolve the dispute:
1. The EN and State VR agency should use the procedures for resolving disputes spelled out
in the agreement or under contracts or interagency agreements contained in State law or
State administrative procedures.
2. If procedures for resolving disputes are not spelled out in the agreement or in State law or
State administrative procedures, the EN or the State VR agency may request that the
OSM recommend a resolution to the dispute. The request must be in writing and include:
• a copy of the agreement;
• information on the issue(s) in dispute; and
• a description of both the EN’s and State VR agency’s position regarding the dispute.
3. The OSM shall recommend a resolution to the dispute within 20 calendar days after
receiving it.
4. If either the EN or the State VR agency does not agree with the OSM’s recommendation,
the EN or the State VR agency has 30 calendar days after receiving the OSM’s
recommendation to request a decision by SSA on the disputed matter. The request to
SSA must:
• be submitted in writing and clearly set forth the issue(s) at hand;
• include the facts and any relevant evidence; and
• contain the details of the OSM's attempted resolution.
SECTION 5: THE EMPLOYMENT NETWORK'S RESPONSIBILITIES TO TICKET
PROGRAM BENEFICIARIES
The EN has the following responsibilities to beneficiaries under the Ticket Program:
1. The EN must provide the beneficiary with a full explanation of the services offered by an EN
under the Ticket Program, so that the beneficiary may make informed choices regarding the
services and the provider who will actually render such services.
2. The EN must protect the beneficiary's personal information, including information about the
beneficiary's disability, from unauthorized disclosure. In order to protect the beneficiary's
personal information the EN shall maintain personal information files in secure locations and
grant access only to authorized individuals.
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PART II – STATEMENT OF WORK
3. The EN must develop and implement the IWP in partnership with the beneficiary. The IWP
must be in written form and signed by both the beneficiary (or the beneficiary's
representative) and the EN indicating mutual agreement.
4. The EN must provide information to the beneficiary regarding the availability of the State
P&A system to assist in resolving disputes between the EN and the beneficiary. The EN
shall provide the beneficiary with the address and phone number of the State P&A system.
5. In addition, the EN shall explain to the beneficiary that:
• The beneficiary may unassign the Ticket at any time if the beneficiary is dissatisfied with
the services being provided.
• The EN may unassign the Ticket at any time if the EN is no longer willing or able to
provide services to the beneficiary.
• The beneficiary may dispute an EN’s refusal to provide employment services, VR
services or other support services after an IWP has been signed in accordance with that
EN's internal dispute resolution procedure. Dispute resolution action must be conducted
by an individual not involved in the issue that precipitated the dispute.
• The beneficiary may refer a dispute first to the OSM for review, and then to SSA through
the OSM for a decision. The EN shall explain the dispute resolution process to the
beneficiary.
• The beneficiary may appoint an individual or legal services organization as a legal
representative to represent the beneficiary in any of the beneficiary's dealings with an EN.
• The beneficiary may have complete access to information in an EN’s records concerning
that beneficiary. Access means that the beneficiary may view the records at the EN place
of business and make copies of the records using the EN's copying equipment. If such
information consists of medical records, the beneficiary may name a representative who
would be willing to review the record and inform the beneficiary of its contents at the
representative’s discretion. Such representative may be a physician, other health
professional, legal representative or other responsible individual.
• The beneficiary may have a copy of the IWP in an accessible format chosen by the
individual.
• The beneficiary may request amendments to the IWP. However, the beneficiary and the
EN must jointly agree to make any changes to the original work plan.
SECTION 6: PRIVACY AND SECURITY REQUIREMENTS FOR EMPLOYMENT
NETWORKS
The EN shall protect the privacy and confidentiality of the information it receives from SSA’s
beneficiary records as follows:
1. Use and access the beneficiary information only for the purposes of SSA’s Ticket Program.
2. Dispose of beneficiary information in a safe and secure manner.
3. Do not duplicate or disseminate beneficiary information within or outside the EN’s
organization.
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4. Provide physical safeguards for protecting the security of the information, including
restricting access to data only to authorized employees and officials who need the data to
perform their official duties in connection with SSA’s Ticket Program.
5. Store the data in a physically secure area and assure that unauthorized personnel cannot
retrieve the data by means of computer, remote terminal or other electronic means.
6. Ensure that all personnel who have access to the data will be advised of:
• the confidential nature of the information
• the safeguards required to protect the information
• the applicability of the Privacy Act (http://www.usdoj.gov/04foia/privstat.htm) to
Government contractors, including the criminal and civil sanctions for noncompliance.
7. Allow SSA and/or its contractor representatives to make on-site inspections or other
provisions for reviewing/auditing the EN’s compliance with the terms of this contract to
ensure that adequate safeguards are being maintained.
SECTION 7: EMPLOYMENT NETWORK TRAINING
A. The EN will be provided training by the OSM—either online at
www.yourtickettowork.com/training or at locations to be determined by the OSM--in
preparation for performing the duties and responsibilities required under the Ticket Program.
B. At a minimum, such training shall cover the following:
• an overview of the original statute establishing the Ticket Program and all subsequent
applicable rules and regulations;
• overview of the Ticket Program including specific program requirements;
• the EN's program responsibilities under the contract;
• Ticket Program operations and processes;
• guidelines for developing an IWP;
• an overview of SSA work incentives;
• beneficiary rights and responsibilities;
• role of the P&A agencies;
• selecting payment options;
• EN capitalization; and
• documentation and reporting requirements.
C. The EN shall be given advance notice by the OSM of all training date(s), locations,
method(s) and formats.
D. The OSM shall provide such training materials as necessary to satisfy the requirements of
this task at no expense to the ENs.
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E. An EN may accept a Ticket and initiate services prior to completion of the training.
SECTION 8: DISPUTE RESOLUTION
A. Resolving Disputes Between Beneficiaries and Employment Networks
1. An EN shall have dispute resolution procedures in place that a beneficiary can use to seek
resolution of any program-related disputes with the EN once an IWP is signed. This
dispute resolution procedure must assure that the beneficiary will receive a full, fair and
timely review of the disputed matter.
2. An EN shall inform each beneficiary of the dispute resolution procedures when:
• the EN and the beneficiary complete and sign the IWP;
• the IWP is changed and
• a dispute arises related to the services identified in the beneficiary’s IWP or related to
the beneficiary’s participation in the Ticket Program.
3. An EN shall inform each beneficiary seeking services that in the event the beneficiary
and the EN cannot resolve their differences the beneficiary may refer a dispute first to the
OSM for resolution, then to SSA for a final decision if the OSM is unable to resolve the
dispute.
4. An EN shall inform each beneficiary that the beneficiary may, at his or her own expense,
be represented by an attorney or other individual of his or her choice at any step in the
dispute process.
5. An EN shall inform each beneficiary of the availability of assistance through the State
P&A System.
6. An EN shall inform each beneficiary that if an acceptable resolution to the dispute cannot
be reached, either the EN or the beneficiary may refer the dispute to the OSM. At the
OSM’s request, the EN shall submit to the OSM all relevant information and evidence
pertaining to the dispute. This shall be submitted to the OSM within ten (10) working
days following receipt of the OSM’s request for information. This information shall
include:
• a description of the disputed issue(s);
• a summary of the beneficiary’s position prepared by the beneficiary or a
representative of the beneficiary related to each disputed issue;
• a summary of the EN’s position related to each disputed issue; and
• a description of any solution proposed by the EN when the beneficiary seeks
resolution through the EN’s dispute resolution procedures.
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The OSM will provide the disputing parties a written recommendation to resolve the
dispute within 20 working days from receipt of all relevant information from the EN.
7. An EN shall inform each beneficiary that if either the beneficiary or the EN is dissatisfied
with a resolution proposed by the OSM, either party may request a decision from SSA.
The EN and/or the beneficiary have 15 working days from receipt of the OSM's
recommendation for dispute resolution to make this request. The OSM, in turn, will have
10 working days to refer the dispute to SSA. SSA will make the final administrative
decision.
8. Either the beneficiary or the EN may terminate the Ticket assignment if unwilling to
accept SSA’s decision.
9. Determinations Regarding Beneficiary Benefits
• An EN cannot appeal SSA's determinations that affect a beneficiary's right to
benefits. Only the beneficiary or his or her representative can appeal these
determinations.
• If an appeal by a beneficiary regarding entitlement or eligibility for disability benefits
results in a revised determination, SSA's revised determination could affect an EN's
payment or result in an adjustment to payments already made to an EN.
• While an EN cannot appeal SSA's determination regarding a beneficiary's right to
benefits, an EN may furnish any evidence it has that may support a change in SSA's
determination on the beneficiary's appeal.
B. Resolving Disputes Between Employment Networks and the OSM
1. The EN shall refer to the OSM, through the OSM's established dispute resolution
procedures, any disputes between the EN and the OSM that do not involve an EN’s
payment request. If a mutually agreeable solution cannot be reached, the OSM, within 20
working days from the date of impasse, will refer the dispute to SSA for a decision. The
OSM shall provide the EN with a copy of all relevant documentation forwarded to SSA,
including:
• a description of the disputed issue(s);
• a summary of the EN’s and OSM’s position; and
• a description of any solution proposed by either the EN or OSM with supporting
justification, as well as the reasons each party rejected each proposed solution.
2. The EN shall maintain records of all disputes referred to SSA and shall provide assistance
to SSA as needed to investigate and resolve each issue.
3. SSA will make the final decision regarding disputes between the EN and the OSM.
SECTION 9: EVALUATING EMPLOYMENT NETWORK PERFORMANCE
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SSA will review periodically the results of the work performed by each EN to provide effective
quality assurance of the provision of services by ENs.
A. These reviews will be governed by performance measurements to be developed by SSA. In
developing these measurements SSA will solicit and consider the views of the consumers the
EN serves, the PM, and the Ticket-to-Work and Work Incentives Improvement Act Work
Incentives Advisory Panel, as well as consult with service providers.
B. The reviews may be conducted by SSA, the OSM or a third party contractor, with input from
Ticket Program support contractors and the beneficiaries served by the EN.
C. SSA will notify the ENs immediately upon issuance of performance standards against which
the quality of EN services will be measured. The EN will be provided a full explanation of
the standards and their application, as well as the nature and timing of the review process.
D. ENs shall make the results of the reviews available to disabled beneficiaries they may serve
to assist these beneficiaries in choosing among available ENs.
E. Performance standards will be incorporated into the EN contract upon issuance of those
standards. An EN's failure to agree to performance standards will result in the termination of
its contract with SSA at no cost to the Government.
SECTION 10: EMPLOYMENT NETWORK REPORTING REQUIREMENTS
Each EN shall submit the following program reports in accordance with the OSM 's instructions.
A. General Requirements
An EN must:
• identify to the OSM each Ticket it accepts;
• submit a copy of each signed IWP to the OSM;
• submit to the OSM copies of amendments to a beneficiary's IWP;
• submit to the OSM a copy of any agreements the EN has reached with State VR agencies
regarding the conditions under which the State VR agency will provide services to
beneficiaries who are referred by the EN under the Ticket Program;
• report to the OSM immediately all instances in which the beneficiary/EN relationship has
ended, either through beneficiary termination, withdrawal or non-active participation, or
the EN’s decision that it is no longer willing or able to provide services to the
beneficiary; and
• collect and record such data as required to support the program requirements of this
solicitation as contained in the Statute (P.L. 106-170), as well as in the Ticket-to-Work
and Self-Sufficiency Program Regulations (20CFR Part 411).
B. Periodic Outcome Report
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1. The EN shall provide to the OSM on no less than an annual basis, in a format prescribed
by SSA, data on outcomes achieved by the EN with respect to services offered by the EN
to beneficiaries. In addition to outcomes, the report shall include data with respect to
beneficiary terminations, withdrawals and non-active participation.
2. The EN shall maintain a copy of the outcome report in each beneficiary’s file.
3. The EN shall ensure that a copy of its most recent periodic outcome report is available to
the general public, while assuring that personal information on beneficiaries is kept
confidential.
4. The EN shall provide a copy of its most recent periodic outcome report to any beneficiary
who contacts the EN regarding assignment of a Ticket to that EN.
C. EN Financial Reports
1. The EN may be asked to provide financial information to SSA with respect to the actual
costs incurred by the EN in providing employment services, VR services or other support
services to Ticket Program beneficiaries.
2. The EN may be asked to provide other fiscal documentation that may be required as a
result of regulations published by SSA.
D. Contract Changes
1. The EN shall inform the OSM of all changes in contract terms and conditions, including
the items identified in Part II (EN Contract Proposal Documentation Requirements).
2. While change requests may be made by telephone they must be submitted in writing
(email is acceptable) to be officially enacted.
3. Only the EN official with signatory authority identified in Part III, Section 2, R.
(Signatory Authority) shall be authorized to request such changes.
SECTION 11: PAYMENTS TO EMPLOYMENT NETWORKS
An EN can elect to be paid under either of 2 payment systems—an outcome payment system or a
milestone-outcome payment system, as described below. (Please complete the requested
information under letter O of the EN Information Sheet found in Part III, Section 2, of this
solicitation.)
A. Selection of Payment System
At the time an EN enters into a contract with SSA the EN shall elect to be paid through either
the outcome payment system or the milestone-outcome payment system. SSA will announce
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PART II – STATEMENT OF WORK
and provide periodic opportunities for ENs to change their payment system elections for
prospective beneficiaries, as follows:
1. An EN may choose to make one change in its elected payment system at any time during
the 12-month period following the later of the month in which the EN first elects an EN
payment system or SSA implements the Ticket-to-Work Program (i.e., begins mailing
Tickets to beneficiaries) in a State served by that EN.
2. SSA will offer the opportunity periodically for ENs to make a change in their elected
payment system. At a minimum, such opportunity shall be offered every 18 months
following implementation of the Ticket Program in the EN's State.
Any change in the elected EN payment system will apply to beneficiaries who assign their
Ticket to the EN after the EN’s change in election becomes effective. A change in the EN’s
election will become effective with the first day of the month following the month in which
the EN notifies the OSM of the change. For beneficiaries who already assigned their Tickets
to the EN under the EN’s earlier elected payment system, the EN’s earlier elected payment
system will continue to apply.
B. Requirements for EN Payments
1. Requirements for Milestone Payments
SSA will pay the EN for up to four (4) milestones achieved by a beneficiary after he/she
has assigned his/her Ticket to the EN provided the outcome-milestone payment system
was the EN’s elected payment system at the time the beneficiary assigned his/her Ticket
to the EN.
• The EN shall request payment for each milestone achieved by a beneficiary who has
assigned a Ticket to the EN.
• The request must include evidence of work or earnings that are more than at the
substantial gainful activity (SGA) threshold amount for the specified number of
months required to achieve the milestone being requested, along with other
information SSA may require to evaluate the EN’s request.
SSA does not have to stop monthly benefit payments to the beneficiary before the EN can
be paid for milestones achieved by the beneficiary.
2. Requirements for Outcome Payments
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a. SSA will pay an EN a monthly outcome payment for an individual who has assigned
his/her Ticket to the EN, provided that 60 monthly outcome payments have not been
made on the Ticket, and the individual:
• Is entitled to or eligible for Federal cash disability or blindness benefits from
Social Security but does not receive them for that month due to work or earnings
or
• Is no longer entitled to or eligible for Federal cash disability or blindness benefits
from Social Security because of work or earnings, has gross earnings from
employment (or net earnings from self-employment) in that month that are more
than the SGA threshold amount, and is not entitled to or eligible for any monthly
benefits under Title II or Title XVI of the Social Security Act for that month
b. The EN shall submit a request for payment for outcome payment months on at least a
quarterly basis. The request must include proof of the beneficiary’s work or earnings
unless the EN currently does not hold the Ticket because it is either unassigned or
assigned to another EN. An EN cannot receive an outcome payment for any month
for which a Social Security disability benefit or a Federal SSI cash disability or
blindness benefit is payable to the beneficiary.
3. Conditions for Receipt of Payments
If the EN's contract is terminated or otherwise ended prior to the beneficiary's
achievement of a milestone or outcome, the EN will not receive any payments for
these milestones or outcomes, nor be entitled to any compensation or payment for
the costs of services provided to the beneficiary.
C. Submitting Requests for EN Payment
1. EN requests for either milestone or outcome payments along with evidence of the
beneficiary’s work or earnings will be sent by the EN to the OSM.
• Evidence of the beneficiary’s work or earnings may include a monthly breakdown of
earnings provided by the beneficiary’s employer (e.g., a statement of monthly
earnings from the employer or the employer’s designated payroll preparer) or (if the
beneficiary does not want the employer to be contacted) evidence that the beneficiary
may have (e.g., an unaltered copy of the beneficiary’s pay slip).
• For an individual who is self-employed, evidence of his or her work activity or
earnings should be obtained from the individual. This would include a signed
statement from the individual with a monthly breakdown of earnings with
corroborating earnings documentation such as copies of the beneficiary’s quarterly
report of estimated income tax or Schedule SE (Computation of Social Security
Self-Employed Tax) from the beneficiary’s annual tax return.
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2. The OSM will receive and review the EN’s request for payment and evidence of the
beneficiary’s work or earnings.
• If the OSM finds sufficient information has been provided, the OSM shall forward the
payment request and work documentation to SSA or
• If the OSM finds sufficient information has not been provided by the EN, the OSM
shall inform the EN and afford the EN an opportunity to take corrective action prior
to forwarding the payment request to SSA.
3. When SSA receives the payment request, SSA will evaluate the evidence of the
beneficiary’s work or earnings for cash benefit effect and determine if payment to the EN
is appropriate. SSA will not make any payments until it receives satisfactory evidence
establishing the EN's entitlement to payment.
4. All payments to an EN will be made via electronic transfer to the EN’s designated
financial institution. To effect this transfer an EN is required to complete Standard Form
3881 (ACH Vendor/Miscellaneous Payment Enrollment Form). This form, along with
instructions for completion, is found in Part III of this solicitation.
SECTION 12: STATUTORY/REGULATORY UNDERSTANDING AND COMPLIANCE
REQUIREMENTS
An offeror shall agree to comply with certain additional conditions in order to be awarded
a contract under this EN solicitation. Specifically, by signing the SF1449 the offeror attests
to the fact that he/she:
1. Agrees to participate in SSA’s Ticket-to-Work and Self-Sufficiency Program; abide by
all the requirements of the solicitation and all the terms of this contract once awarded;
2. Understands the program requirements of this solicitation as contained in the statute (P.L.
106-170), as well as in the Ticket-to-Work and Self-Sufficiency Program (20 CFR Part
411) regulations.
3. Has read and understands this solicitation, and all attached addenda and amendments
thereto (if any);
4. Agrees to comply with all of the statutory requirements and Federal regulations
governing SSA’s Ticket-to-Work and Self-Sufficiency Program;
5. Agrees to cooperate fully with SSA’s OSM contractor in the administration of Ticket
Program operations and processes in support of the Statute and Ticket Program
regulations cited above; and
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6. Agrees that any provider(s) with which the EN subcontracts, meets all of the qualification
requirements found in Part II, Section 1, and the privacy and security requirements found
in Part II, Section 6, of this solicitation.
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PART III – EN PROPOSAL DOCUMENTATION REQUIREMENTS
[IMPORTANT]
Sections 1-5 below shall be completed in their entirety and submitted to the ENCT as instructed
in the cover letter to this solicitation.
SECTION 1: Instructions for Completing Standard Form SF-1449
The Standard Form 1449 as shown below, or that also can be downloaded from the SSA
work web site www.ssa.gov/work, must be completed and submitted with your proposal.
Although page 2 does NOT require your fill-in, you must submit it in order for the form to
be considered complete.
You must fill in the following blocks on the SF 1449 form shown on the next page (as
highlighted in yellow):
Block 17a
Please provide the name of the EN, address (no post office boxes), telephone number, and
Employer Identification Number (EIN). If further guidance is needed regarding the EIN, please
see Part III, Section 2-C (Employer Identification Number).
Block 17b
If the remittance address is different than the address in block 17a, check this block and include
the remittance address in offer. This address may be a post office box.
Block 30a
Please provide a legible original signature, of an authorized official of your organization.
Block 30b
Please print or type the name and title of the individual that signed in block 30a.
Block 30c
Please enter the current date in this block.
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SECTION 2: EN INFORMATION SHEET
A. OFFEROR’S NAME (name of organization/entity submitting proposal):
_______________________________________________________________________
B. NAME OF EMPLOYMENT NETWORK (if different from item A above):
_______________________________________________________________________
C. EN’S EMPLOYER IDENTIFICATION NUMBER (EIN):
_______________________________________________________________________
(The offeror must have an EIN and the EIN must be issued in the name of the EN shown
in item B above. An EIN may be obtained from the Internal Revenue Service by calling
1-800-829-1040 or via the web at www.irs.gov. We cannot accept a Social Security
Number in lieu of an EIN. Any questions regarding this requirement should be directed to
the ENCT as instructed in the cover letter to this solicitation.)
D. EN’S DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER:
_______________________________________________________________________
(The DUNS number is a 9-digit number assigned by Dun & Bradstreet Information
Services. Every EN must have a DUNS number. If an offeror does not already have a
DUNS number, one may be obtained directly from Dun & Bradstreet at 1-800-333-0505.
A DUNS number will be provided immediately by telephone at no charge to the offeror.
The DUNS number must be issued in the EN name shown in item B above.)
E. ADDRESS (no post office boxes):
___________________________________________________________________
__________________________________________________________________
__________________________________________________________________
F. MAILING ADDRESS (if different from above. May be post office box.):
___________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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G. LOCATION OF SERVICES
a. Will services to beneficiaries be provided at the location shown in E above?
Yes [ ] No [ ]
b. Will services to beneficiaries be provided at other locations? *Yes [ ] No [ ]
*If “yes”, and you want these additional locations to appear on the Ticket to Work
website, please fill in the Information Sheet — Addendum (attached) for EACH
additional location.
H. EN DIRECTORY CONTACT INFORMATION
Please provide the information requested below to facilitate beneficiary contact with your
EN. This information will appear in the online EN Directory at. At a minimum all ENs
will be required to show an address and telephone number in the EN Directory. For
those ENs with multiple service areas covered by one local telephone exchange, the
EN must provide a toll-free telephone number.
a. CONTACT NAME: ________________________________
b. PHONE: (____)______-___________ c. TOLL FREE #: (____)_____-
_________
d. FAX: (____)_____ -____________ e. TTY: (____)____ -_____________
f. EMAIL: ________________________________________
g. WEBSITE: __________________________________________________________
Do you want a link to this website on the Employment Network Directory?
Yes [ ] No [ ]
I. OTHER EN CONTACTS
Please list the following contact information for all other program/contract inquiries if
different from item H above:
a. CONTACT NAME: ________________________________
b. PHONE: (____)______-___________ c. TOLL FREE #: (____)_____-
_________
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d. FAX: (____)_____ -____________ e. TTY: (____)____
-_____________
f. EMAIL: _________________________________________
J. SERVICE AREA
Please check one only. This will be listed in the online EN Directory and you may be
contacted by beneficiaries living in the service area you designate.
[ ] National (serving all states and U.S. Territories)
[ ] Multi-State (list all states you will serve using the 2-letter state abbreviation)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
___
[ ] Single State (list the state using the 2-letter state abbreviation)
_________________________________________________________________
For each state you are serving in which you are serving only a selected county(s),
please list the state (using the 2-letter state abbreviation), followed by the selected
county(s):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
For each state you are serving in which you are serving selected zip codes, please list
the state (using the 2- letter state abbreviation), followed by the selected zip code(s):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
K. CORPORATE STATUS (check all thaty apply)
 Business Consortium/Association
 Corporation engaged in the billing/collection of payments for medical and health
care services
 Corporation providing medical and health care services
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 Psychosocial rehabilitation
 Referral to services or support from local mental health or developmental
disabilities providers
 School to work transition services
 Self-employment/business start-up
 Services under a formal agreement with a Workforce Investment Board and/or
One-Stop
 Special language capacity (i.e. Spanish, Vietnamese, Russian, Sign Language,
etc...) Please List:
_____________________________________________________________________
 Supported employment
 Situational assessment
 Transitional Employment Program
 Transportation assistance
 Work incentives counseling
 Other services: --------____________________________________________________
O. EN PAYMENT SYSTEM ELECTION (Reference Part II, Section 11A, of this
solicitation.) The offeror shall select a payment system by checking one (1) of the two
(2) boxes shown below:
[ ] Milestone/outcome payment
[ ] Outcome payment
P. EN QUALIFICATIONS REQUIREMENTS (Reference Part II, Section 1A, of this
solicitation.) The undersigned is submitting one of the following as evidence of
qualifications to provide EN services for SSA:
[ ] a copy of a current license or certification to provide employment services, VR
services or other support services in the State(s) of __________________ is
attached; or
because there is no licensing or certification requirement in the State(s) shown
above I am submitting the following documentation:
[ ] A copy of a current certification or accreditation that establishes qualifications to
provide or arrange for the provision of employment services, VR services or other
support services; or
[ ] Other documentation showing education and/or experience that clearly
demonstrates qualifications to provide or arrange for the provision of employment
services, VR services or other support services.
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Q. INDEMNIFICATION AND LIABILITY INSURANCE (Reference Part IV, Section
5, of this solicitation.)
a. The undersigned has read, understood, and agrees to comply with the
requirements for indemnification and liability insurance under the EN
program if awarded a contract.
b. The undersigned is submitting proof of the following insurance:
(Check all that apply)
[] general liability insurance with a minimum coverage of $500,000 per
occurrence.
[] professional liability insurance with a minimum coverage of $500,000 per
occurrence.
[] medical liability insurance with a minimum coverage of $500,000 per
occurrence
c. As proof of current insurance coverage, the undersigned is submitting:
[] a certificate of insurance issued by the insurance company, agent or
broker; or
[] a copy of the insurance policy.
R. SIGNATORY AUTHORITY
Only the EN official with signatory authority shall be authorized to request contract
changes. See Part II-Section 10.D (Contract Changes).
Name Typed: __________________________________________
Title: ___________________________________________
Signature: ___________________________________________
Date: ___________________________________________
Telephone # ___________________________________________
FAX # ___________________________________________
EMail Address ___________________________________________
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SECTION 3: INFORMATION SHEET — ADDENDUM
The information sheet shown in subsection 2 above should be completed for each additional or
different location, access information and/or service the offeror wishes to be published publicly
for beneficiaries in the online EN Directory at www.yourtickettowork.com. Please fill out one
addendum for EACH different service delivery location.
SECTION 4: ACH VENDOR/MISCELLANEOUS PAYMENT ENROLLMENT FORM
This form must be completed and submitted with your proposal to allow us to direct payments
electronically to your designated account.
Under the portion of the form entitled Financial Institution Information:
• Where the form requests "Depositor Account Title" - this is the name which should
appear on the check.
• The shaded signature block entitled "Signature and Title of Authorized Official” at
the bottom of the form is to be completed by the bank official only.
Contract award will not be made until this form is received.
The information provided by the offeror on this form is for government use only for this
requirement, to facilitate the electronic payment from SSA to the EN contractor and will not be
released to entities outside of the OSM contractor, SSA or your designated financial institution.
Any questions regarding this form should be directed to the ENCT per instructions found in the
cover letter to this solicitation.
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SECTION 5: 52.212-3 -- OFFEROR REPRESENTATIONS AND CERTIFICATIONS --
COMMERCIAL ITEMS (NOV 2006)
[IMPORTANT]
An Offeror shall complete only paragraph (k) of this provision if the Offeror has completed the
annual representations and certificates electronically at http://orca.bpn.gov . If an Offeror has not
completed the annual representations and certifications electronically at the ORCA website, the
Offeror shall complete only paragraphs (b) through (j) of this provision.
(a) Definitions. As used in this provision--
“Emerging small business” means a small business concern whose size is no greater than
50 percent of the numerical size standard for the NAICS code designated.
“Forced or indentured child labor” means all work or service—
(1) Exacted from any person under the age of 18 under the menace of any penalty
for its nonperformance and for which the worker does not offer himself voluntarily;
or
(2) Performed by any person under the age of 18 pursuant to a contract the
enforcement of which can be accomplished by process or penalties.
“Manufactured end product” means any end product in Federal Supply Classes (FSC)
1000-9999, except—
(1) FSC 5510, Lumber and Related Basic Wood Materials;
(2) Federal Supply Group (FSG) 87, Agricultural Supplies;
(3) FSG 88, Live Animals;
(4) FSG 89, Food and Related Consumables;
(5) FSC 9410, Crude Grades of Plant Materials;
(6) FSC 9430, Miscellaneous Crude Animal Products, Inedible;
(7) FSC 9440, Miscellaneous Crude Agricultural and Forestry Products;
(8) FSC 9610, Ores;
(9) FSC 9620, Minerals, Natural and Synthetic; and
(10) FSC 9630, Additive Metal Materials.
“Place of manufacture” means the place where an end product is assembled out of
components, or otherwise made or processed from raw materials into the finished product
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that is to be provided to the Government. If a product is disassembled and reassembled, the
place of reassembly is not the place of manufacture.
“Service-disabled veteran-owned small business concern”—
(1) Means a small business concern—
(i) Not less than 51 percent of which is owned by one or more service-
disabled veterans or, in the case of any publicly owned business, not less
than 51 percent of the stock of which is owned by one or more service-
disabled veterans; and
(ii) The management and daily business operations of which are controlled
by one or more service-disabled veterans or, in the case of a service-
disabled veteran with permanent and severe disability, the spouse or
permanent caregiver of such veteran.
(2) Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with
a disability that is service-connected, as defined in 38 U.S.C. 101(16).
“Small business concern” means a concern, including its affiliates, that is independently
owned and operated, not dominant in the field of operation in which it is bidding on
Government contracts, and qualified as a small business under the criteria in 13 CFR Part
121 and size standards in this solicitation.
“Veteran-owned small business concern” means a small business concern—
(1) Not less than 51 percent of which is owned by one or more veterans(as defined
at 38 U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51
percent of the stock of which is owned by one or more veterans; and
(2) The management and daily business operations of which are controlled by one
or more veterans.
“Women-owned business concern” means a concern which is at least 51 percent owned by
one or more women; or in the case of any publicly owned business, at least 51 percent of
the its stock is owned by one or more women; and whose management and daily business
operations are controlled by one or more women.
“Women-owned small business concern” means a small business concern --
(1) That is at least 51 percent owned by one or more women or, in the case of any publicly
owned business, at least 51 percent of the stock of which is owned by one or more women;
and
(2) Whose management and daily business operations are controlled by one or more
women.
(b) Taxpayer identification number (TIN) (26 U.S.C. 6109, 31 U.S.C. 7701). (Not applicable if the Offeror
is required to provide this information to a central contractor registration database to be eligible for
award.)
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(1) All Offerors must submit the information required in paragraphs (b)(3) through (b)(5)
of this provision to comply with debt collection requirements of 31 U.S.C. 7701(c) and
3325(d), reporting requirements of 26 U.S.C. 6041, 6041A, and 6050M, and implementing
regulations issued by the Internal Revenue Service (IRS).
(2) The TIN may be used by the government to collect and report on any delinquent
amounts arising out of the Offeror’s relationship with the Government (31 U.S.C. 7701(c)
(3)). If the resulting contract is subject to the payment reporting requirements described in
FAR 4.904, the TIN provided hereunder may be matched with IRS records to verify the
accuracy of the Offeror’s TIN.]
Due to the structure of the database for payment to EN’s, the offeror shall NOT cite its
Social Security Number (SSN) as the TIN. Instead, offerors must obtain a unique
identification number, referred to as an Employer Identification Number (EIN), to
substitute for a SSN. The EIN may be obtained, free of charge, by contacting the Internal
Revenue Service (IRS) at 1-800-829-1040 or via their website at www.irs.gov. Any
questions regarding this issue shall be directed to the ENCT as referenced in the RFP cover
letter.
(3) Taxpayer Identification Number (TIN).
[ ] TIN:_____________________.
[ ] TIN has been applied for.
[ ] TIN is not required because:
[ ] Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not
have income effectively connected with the conduct of a trade or business in the United
States and does not have an office or place of business or a fiscal paying agent in the
United States;
[ ] Offeror is an agency or instrumentality of a foreign government;
[ ] Offeror is an agency or instrumentality of the Federal Government;
(4) Type of organization.
[ ] Sole proprietorship;
[ ] Partnership;
[ ] Corporate entity (not tax-exempt);
[ ] Corporate entity (tax-exempt);
[ ] Government entity (Federal, State, or local);
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[ ] Foreign government;
[ ] International organization per 26 CFR 1.6049-4;
[ ] Other ____________________.
(5) Common parent.
[ ] Offeror is not owned or controlled by a common parent:
[ ] Name and TIN of common parent:
Name ____________________________________
TIN ______________________________________
(c) Offerors must complete the following representations when the resulting contract is to be performed in
the United States or its outlying areas. Check all that apply.
(1) Small business concern. The Offeror represents as part of its offer that it [ ] is, [ ] is
not a small business concern.
(2) Veteran-owned small business concern. [Complete only if the Offeror represented itself
as a small business concern in paragraph (c)(1) of this provision.] The Offeror represents
as part of its offer that it [ ] is, [ ] is not a veteran-owned small business concern.
(3) Service-disabled veteran-owned small business concern. [Complete only if the Offeror
represented itself as a veteran-owned small business concern in paragraph (c)(2) of this
provision.] The Offeror represents as part of its offer that it [ ] is, [ ] is not a service-
disabled veteran-owned small business concern.
(4) Small disadvantaged business concern. [Complete only if the Offeror represented itself
as a small business concern in paragraph (c)(1) of this provision.] The Offeror represents,
for general statistical purposes, that it [ ] is, [ ] is not, a small disadvantaged business
concern as defined in 13 CFR 124.1002.
(5) Women-owned small business concern. [Complete only if the Offeror represented itself
as a small business concern in paragraph (c)(1) of this provision.] The Offeror represents
that it [ ] is, [ ] is not a women-owned small business concern.
Note: Complete paragraphs (c)(6) and (c)(7) only if this solicitation is expected to exceed
the simplified acquisition threshold.
(6) Women-owned business concern (other than small business concern). [Complete only
if the Offeror is a women-owned business concern and did not represent itself as a small
business concern in paragraph (c)(1) of this provision.]. The Offeror represents that it [ ]
is, a women-owned business concern.
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(7) Tie bid priority for labor surplus area concerns. If this is an invitation for bid, small
business Offerors may identify the labor surplus areas in which costs to be incurred on
account of manufacturing or production (by Offeror or first-tier subcontractors) amount to
more than 50 percent of the contract price:
___________________________________________
(8) Small Business Size for the Small Business Competitiveness Demonstration Program
and for the Targeted Industry Categories under the Small Business Competitiveness
Demonstration Program. [Complete only if the Offeror has represented itself to be a small
business concern under the size standards for this solicitation.]
(i) [Complete only for solicitations indicated in an addendum as being set-aside for
emerging small businesses in one of the designated industry groups (DIGs).] The
Offeror represents as part of its offer that it [ ] is, [ ] is not an emerging small
business.
(ii) [Complete only for solicitations indicated in an addendum as being for one of
the targeted industry categories (TICs) or designated industry groups (DIGs).]
Offeror represents as follows:
(A) Offeror’s number of employees for the past 12 months (check the
Employees column if size standard stated in the solicitation is expressed in
terms of number of employees); or
(B) Offeror’s average annual gross revenue for the last 3 fiscal years (check
the Average Annual Gross Number of Revenues column if size standard
stated in the solicitation is expressed in terms of annual receipts).
(Check one of the following):
Number of Employees Average Annual Gross Revenues
50 or fewer $1 million or less
51-100 $1,000,001-$2 million
101-250 $2,000,001-$3.5 million
251-500 $3,500,001-$5 million
501-750 $5,000,001-$10 million
751-1,000 $10,000,001-$17 million
Over 1,000 Over $17 million
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(9) [Complete only if the solicitation contains the clause at FAR 52.219-23, Notice of Price
Evaluation Adjustment for Small Disadvantaged Business Concerns, or FAR 52.219-25,
Small Disadvantaged Business Participation Program—Disadvantaged Status and
Reporting, and the Offeror desires a benefit based on its disadvantaged status.]
(i) General. The Offeror represents that either—
(A) It [ ] is, [ ] is not certified by the Small Business Administration as a
small disadvantaged business concern and identified, on the date of this
representation, as a certified small disadvantaged business concern in the
database maintained by the Small Business Administration (PRO-Net), and
that no material change in disadvantaged ownership and control has
occurred since its certification, and, where the concern is owned by one or
more individuals claiming disadvantaged status, the net worth of each
individual upon whom the certification is based does not exceed $750,000
after taking into account the applicable exclusions set forth at 13 CFR
124.104(c)(2); or
(B) It [ ]has, [ ] has not submitted a completed application to the Small
Business Administration or a Private Certifier to be certified as a small
disadvantaged business concern in accordance with 13 CFR 124, Subpart B,
and a decision on that application is pending, and that no material change in
disadvantaged ownership and control has occurred since its application was
submitted.
(ii) Joint Ventures under the Price Evaluation Adjustment for Small Disadvantaged
Business Concerns. The Offeror represents, as part of its offer, that it is a joint
venture that complies with the requirements in 13 CFR 124.1002(f) and that the
representation in paragraph (c)(9)(i) of this provision is accurate for the small
disadvantaged business concern that is participating in the joint venture. [The
Offeror shall enter the name of the small disadvantaged business concern that is
participating in the joint venture: ________________.]
(10) HUBZone small business concern. [Complete only if the Offeror represented itself as
a small business concern in paragraph (c)(1) of this provision.] The Offeror represents, as
part of its offer, that--
(i) It [ ] is, [ ] is not a HUBZone small business concern listed, on the date of this
representation, on the List of Qualified HUBZone Small Business Concerns
maintained by the Small Business Administration, and no material change in
ownership and control, principal office, or HUBZone employee percentage has
occurred since it was certified by the Small Business Administration in accordance
with 13 CFR part 126; and
(ii) It [ ] is, [ ] not a joint venture that complies with the requirements of 13 CFR
part 126, and the representation in paragraph (c)(10)(i) of this provision is accurate
for the HUBZone small business concern or concerns that are participating in the
joint venture. [The Offeror shall enter the name or names of the HUBZone small
business concern or concerns that are participating in the joint venture:
37

39.
SSA-RFP-07-0010F
PART III - EN PROPOSAL DOCUMENTATION REQUIREMENTS
__________.] Each HUBZone small business concern participating in the joint
venture shall submit a separate signed copy of the HUBZone representation.
(d) Representations required to implement provisions of Executive Order 11246 --
(1) Previous contracts and compliance. The Offeror represents that --
(i) It [ ] has, [ ] has not, participated in a previous contract or subcontract subject
to the Equal Opportunity clause of this solicitation; and
(ii) It [ ] has, [ ] has not, filed all required compliance reports.
(2) Affirmative Action Compliance. The Offeror represents that --
(i) It [ ] has developed and has on file, [ ] has not developed and does not have on
file, at each establishment, affirmative action programs required by rules and
regulations of the Secretary of Labor (41 CFR parts 60-1 and 60-2), or
(ii) It [ ] has not previously had contracts subject to the written affirmative action
programs requirement of the rules and regulations of the Secretary of Labor.
(e) Certification Regarding Payments to Influence Federal Transactions (31 U.S.C. 1352). (Applies only
if the contract is expected to exceed $100,000.) By submission of its offer, the Offeror certifies to the best
of its knowledge and belief that no Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress or an employee of a Member of Congress on his or her
behalf in connection with the award of any resultant contract.
(f) Buy American Act Certificate. (Applies only if the clause at Federal Acquisition Regulation (FAR)
52.225-1, Buy American Act – Supplies, is included in this solicitation.)
The Offeror certifies that each end product, except those listed in paragraph (f)(2) of this
provision, is a domestic end product and that the Offeror has considered components of
unknown origin to have been mined, produced, or manufactured outside the United States.
The Offeror shall list as foreign end products those end products manufactured in the
United States that do not qualify as domestic end products. The terms “component,”
“domestic end product,” “end product,” “foreign end product,” and “United States” are
defined in the clause of this solicitation entitled “Buy American Act—Supplies.”
Foreign End Products:
LINE ITEM NO. COUNTRY OF ORIGIN
[List as necessary]
(3) The Government will evaluate offers in accordance with the policies and procedures of
FAR Part 25.
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